Introduction

A patient’s right to considerate and respectful care was enshrined in the American Hospital Association’s “A Patient’s Bill of Rights” in 1973. However, poor clinical practice continues, and too many doctors remain cold, indifferent and emotionally detached from their patients, showing little concern or empathy for their plight.

One explanation for the persistence of such poor clinical practice is that reformers have not fully taken account of the “institutional” variables that shape healthcare. These variables – which include legislation, regulation, licensing, governance and leadership – form the parameters in which healthcare organizations operate, and constrain reformers’ room to maneuver, and their ability to make change.

To illustrate how institutional variables impact on healthcare practice, we draw upon a real-life clinical encounter highlighting poor doctor-patient interaction to uncover how and why patient care remains unchanged. Reframing the problem in institutional terms yields new insight into why attempts to improve physicians’ interpersonal and communication skills have proved futile, and why an impasse remains in the doctor-patient relationship.

The Clinical Encounter

A clinical encounter involving the teaching of communication and interpersonal skills,helps show how institutionalvariables operate to subvert medical education and clinical practice. Although vital to effective diagnosis and treatment, and correlated with improved health outcomes, these skillsremain wanting in all too many doctors.

The encounter occurred during a clinical rotation at a U.S. teaching hospital, where a patient diagnosed with lung cancer asked if she would die. The attending physician simply replied “Yes,” and upon hearing the bad news, the patient burst into tears. No member of the medical team said anything, or interacted with the patient in any way, and all promptly left the bedside.

The Institutional Dynamics of Medical Education and Clinical Practice

Recalling the encounter, a third-year medical student reported that she had wanted to sit beside the patient, comfort her with a hug, and reassure her. However, she had not done so despite the fact that her actions would have accorded with best practice guidelines issued by the American Medical Association (AMA), and the Association of American Medical Colleges (AAMC). The AMA’s Code of Medical Ethics specifies that “[t]he patient has the right to courtesy, respect, dignity, responsiveness, and timely attention to his or her needs.” Similarly, according to the AAMC, physicians should express care, concern, and empathy to patients; facilitate emotional ventilation by giving them the opportunity to talk; and enable the exchange of information on treatment options and palliative care.

Regardless of copious documentation and guidance, the response of the attending physician and his team clearly ran counter to these established clinical practice guidelines. Such actions are common and reflect the norm in clinical practice, with many physicians providing little emotional support to their patients, despite their need for reassurance and comfort.The disconnect between intentions and outcomes arises due to the institutional variables that underpin medical education and clinical practice. These variables act to thwart the intentions of reformers in relation to interpersonal and communication skills in particular, and healthcare practice in general.

The Institutional Variable of Leadership

When questioned why she had held back from responding empathically to the patient’s distress, the student reported that she had been waiting for signs from the attending physician that would allow her to reassure the patient. Since none were forthcoming, she felt that she had little option but to take his lead, and mirror his behavior.

This response reveals that the actions of leaders send out strong signals that convey that the lessons learned in the classroom are not necessarily relevant in real-world clinical practice. Such actions reflect the considerable authority that leaders possess, and show that their behavior is the ultimate marker as to what is acceptable. Our student realized that it was more important to emulate the actions of the head of the medical team than to respond empathically to the patient.

The clinical encounter highlights the power of the institutional variable of “leadership,” explaining why reforms to clinical practice are often unsuccessful. Leaders mold the responses and behaviors of those they lead. When leaders pay lip service to or flout guidelines, their actions sanction and perpetuate inappropriate behaviors and practices. If healthcare reformers are to make real progress in transforming medicine, they need to appreciate the pivotal role that leaders play in the clinical setting.

The Institutional Variable of Hierarchy

Our student further disclosed that she had also sought cues from the other members of the medical team to give her the “green light” to act. However, since they also took their lead from the attending physician, they too maintained a stony exterior. This reinforced to the student that she should not show compassion towards the patient. Moreover, the student disclosed that her response was further conditioned by her awareness of her junior position, and that she realized that it was more important for her to respect the hospital hierarchy than respond to the patient’s needs. For those lower in the hierarchy, it is more important to observe and adhere to the pecking order, and not break ranks, than to communicate and respond empathically with patients.

The hospital hierarchy is characterized by strictly defined positions and roles, and is deeply entrenched and absolute. This hierarchy cannot be easily questioned or confronted, and imposes severe consequences on those who transgress its strictly ordered system.

Whilst the institutional variable of “hierarchy” is essential to the practice of medicine, it also has the power to distort what students learn, and the behaviors they eventually adopt. Ultimately, strong and deep-seated hierarchies limit reform of medical education and clinical practice.

Institutional Rigidity

The institutional variables of leadership and hierarchy combine to create “institutional rigidity,” that is, an organizational environment in which existing systems and practices remain deep-seated and incontestable. Institutional rigidity acts as a brake on medical reform, reinforcing and perpetuating existing clinical practices, and makes reform of the communication and interpersonal skills of physicians difficult to achieve and embed.

The Way Forward

The clinical encounter forces us to confront the real-world complexity and difficulties associated with transforming clinical practice. It highlights the fundamental role of institutional variables such as leadership and hierarchy, demonstrating that power and control still rest firmly in the hands of physicians – some of whom remain emotionally detached and show little empathy towards their patients – and explains why clinical practice remains unchanged. If we are to transform clinical practice, those in charge of reforming healthcare need to take a lead in adopting an institutional perspective when dealing with organizational change.

To this end, reformers, when thinking about organizational change, need to be awarethat “institutional” variables are often at play and that in the hospital setting, some physicians wish to maintain the status quo, and so are resistant to organizational change – since reforms can “diminish” their dominance and power within the hierarchy. This inertia, in the form of institutional rigidity, often comes at a cost, and so reformers must identify sources of resistance, and determine how this resistance impacts on the performance of an organization,and ultimately, on patient care. Thus, reformers need to engage in transformational processes that challenge vested interests, so that changes to healthcare are in the interests of patient care, and not those of groups or individuals seeking to serve their own agendas.

Whilst change is difficult, reformers need to be led by the fact that it is patients who are ultimately the most important variable. Only by adopting an institutional approachcan reformers hope to make significant inroads in breaking the doctor-patient relationship impasse,reform healthcare and transform clinical practice.

They have worked at senior and executive levels in the United States, United Kingdom, and New Zealand, andhave previously published “Developing Leadership in Medicine: The Importance of “Institutional Awareness” and “Understanding the “Rules of the Game” in Healthcare Reform,” in Healthcare Reform Magazine.